Considering radiation: What are the treatment options?

Is your Gleason 7 a 3+4 or a 4+3?

With your Gleason 7, what % were “4” cell types?

Did your MRI report or biopsy report mention anything about: cribriform pattern, extracapsular extension, seminal vesicle invasion, perineural invasion or intraductal carcinoma?

What is it about your diagnosis that requires a brachy boost?

(All of those answers and other results help guide your treatment protocol.)

With the recommended 23 external radiation treatments over 4.5 wks, how many grays of radiation each treatment (or how many grays total)?

I had 28 sessions of proton radiation + 6 months of ADT. I did not have brachytherapy.

If they can do SBRT radiation, they can get it over in five sessions. There are a lot of radiation oncologist that do that instead of IMRT with 4 to 8 weeks.

They could also do the brachytherapy if still necessary, They can actually do that first.

You may not need it if you have SBRT.

You probably need to speak to another RO. With a Gleason score of seven SBRT is very common. My brother had it, it worked great. I know somebody with a Gleason eight that had it and is still fine 17 years later..

@jeffmarc thank you! This was very useful!

@newjersey2
I believe you asked for those who had radiation treatments for the P.C. And I presume you are deciding and getting your first recommendations. Remember you can always get a second opinion.

I had 30 rounds of proton radiation in 2023. What you should be asking (your doctors) is about the difference in getting a high dose versus low dose and the pros and cons of each.

I can only pass on to you the guidance I got from my Mayo R/O, my UFHPTI R/O, and Mayo PCP. They all explained the high does is indeed much quicker but requires a higher dose of radiation and can cause quicker side affects and for some increased based on the individual not a statistic.

My R/O at UFHPTI stated he does not like the high dose less days. He stated his research and what his is seeing from doing 20 years of radiation treatments for P.C. is that he sees increase in side affects quicker and in some cases additional or more severe. Thus from his experience as a R/O for over 20 years it is why he recommends the low dose extended days.

My PCP at Mayo said the same thing. Probably all of us would prefer less days of treatments but you need to be briefed by your medical doctors the pros and cons of each. Only they are the professional trained medical doctors, trained in doing radiation treatments and can give you hands of feedback of their professional experience. You doctors are the only individuals who have examined you, and know you full medical and mental health history.

You are an individual and have an individual cancer that needs to be treated specifically for what is best for you not what was best for another or "I heard or read this or that."

Good luck. If you are in doubt and most of us were, consider getting a second opinion. I did and got the same recommendation for me and why they chose that treatment based on my specific test results and my full medical and mental health history.

I am also a bit surprised about the need for a brachy boost. I was treated for prostate cancer some ten years ago and at that time, five sessions of SBRT was the standard for low PSA, low Gleason score, (non-metastatic) patients in the radiation oncology department where I was helped. I concur that you should find out more about that issue and a second consultation would be a wise path to follow, if possible.
As pointed out already, you should also ask whether a short course of ADT would improve the statistics for your case.

PS: Very much in general, more intense radiation therapy (like, in your case, 5 x SBRT) will increase the likelihood of late side effects.

For SBRT should get PROSTOX Ultra test (genetic) to determine risk of late stage urinary side effects from SBRT. HDR Brachytherapy is usually a standalone treatment for low-risk prostate cancer since it can cover the prostate at higher doses than IMRT or SBRT. Do you have 4+3 with a high percentage of 4? IMRT/SBRT can treat areas outside the prostate for lymph nodes, etc. that HDR cannot and micro-metastasis (not able to pick up on PET scan) in the local area is much more likely with 4+3 than 3+4. Need to find out what the RO was planning to cover and also get second opinion from another RO that does SBRT and see what they recommend.

The studies show 5 sessions of SBRT equal to 23+ sessions of IMRT with success rate with BCR, survival (see below) . Late term toxicities may actually be a little better with SBRT. You may have some worse side effects at first with SBRT but just for a few months. There is a test called Prostox "Ultra" that will show the chances of late term SBRT side effects or the regular Prostox test which will show same for regular radiation, IMRT, etc.
Many centers of excellence are doing HDR brachytherapy along with 5 sessions of SBRT or 23-25 sessions of IMRT but usually for higher risk patients. The brachy can be done before or after radiation.
The treatment comes down to risk category and/or the doctor's preference.

Effectiveness (Cancer Control)Outcomes: Large clinical trials (such as PACE-B) show that 5-session SBRT is just as effective as conventional or moderately hypofractionated radiation (like IMRT) at keeping intermediate-risk, localized prostate cancer from returning over 5 years.Side Effects and Quality of LifeBowel Health: Recent clinical studies (such as NRG-GU005) indicate that SBRT can actually improve bowel health-related quality of life compared to standard/moderately hypofractionated radiation.Severe Complications: Severe urinary or bowel complications are rare with both methods, though modern delivery and tools like rectal spacers help minimize tissue exposure in both groups.

Fewer patients treated with SBRT reported a clinically meaningful decline in bowel function at two years (34.9% vs. 43.8% with MH-IMRT, p=0.034). Overall urinary quality of life was equivalent between the groups, but urinary incontinence was less common two years after SBRT (declines for 25.9% vs. 34.7% with MH-IMRT, p=0.023). Sexual function scores favored SBRT at one year (34% vs. 44%, respectively, p=0.026) but were similar at two years (43 vs. 41%, p=0.67).

PACE B showed SBRT to be as effective as longer course external beam at treating localized cancer, for low to intermediate risk patients. However, it found that SBRT was a bit more toxic.

Quoting from an article that discussed PACE B: "SBRT May Be Effective in Managing Intermediate-Risk Prostate Cancer" https://www.curetoday.com/view/sbrt-may-be-effective-in-managing-intermediate-risk-prostate-cancer

"Grade 2 or higher genitourinary side effects from radiation at five years were reported in 26 of the 355 patients who were treated with SBRT compared with 16 patients who received traditional radiation therapy. General grade 2 or higher genitourinary side effects occurred in 31 of 355 patients from the SBRT group versus 24 patients in the traditional radiation group, according to the study.

At five years, grade 2 or higher gastrointestinal side effects from radiation occurred in three patients who were treated with SBRT and in one patient treated with traditional radiation. Grade 2 or higher erectile dysfunction at five years occurred in 78 and 86 patients in the SBRT and traditional radiation groups, respectively.

Overall, 79 patients died in the study, with 46 from the SBRT group and 33 in the traditional radiation group. Four of these deaths were because of prostate cancer (two from each group). There were 28 deaths among patients which were because of other primary cancers, the researchers stated in the study."

If the doctor is recommending an HDR boost it sounds like you are unfavorable intermediate, or for some reason, even high risk. External beam plus HDR boost gives the highest radiation dose possible to the prostate, higher than is safely possible with any external beam alone, which translates into longer freedom from biochemical failure.

My case was classified as "at least high risk", cT3b, i.e. proven to have invaded the seminal vesicles, i.e. outside the gland already. My RO at first suggested SBRT. He said he had proven to himself it was as good and not particularly more toxic than 20 sessions of EBRT but because his study was not randomized he could not say it was proven to the highest standard. But when I asked for and he approved of an HDR boost, he then recommended 20 sessions of EBRT. I think he wanted to be conservative with me because of my age. (76).

I think the trend is for most patients to choose SBRT, for the convenience factor.

Dr. Neil Desai was interviewed about all the factors he takes into account when deciding on radiation treatment for unfavorable intermediate PCa in this following video. He says where he practices, in Dallas Texas, almost all his patients want SBRT.

@jc76 thank you. I am getting 2md and 3rd opinions.

@climateguy thnk you! This was very insightful!